When EMS Should Not Initiate CPR
EMS personnel should withhold CPR in three specific circumstances: when obvious signs of irreversible death are present (decapitation, rigor mortis, dependent lividity, decomposition), when a valid DNAR order exists, or when attempting resuscitation would place the rescuer at serious risk of injury or death. 1
Absolute Contraindications to Starting CPR
Signs of Irreversible Death
EMS must not initiate resuscitation when any of the following are present:
- Decapitation or hemicorporectomy 1
- Rigor mortis (stiffening of muscles after death) 1
- Dependent lividity (pooling of blood in dependent body parts, appearing as purple discoloration) 1
- Decomposition (visible tissue breakdown) 1
- Transection (body severed in half) 1
These signs provide objective evidence that death is irreversible, making CPR futile. 1
Valid DNAR Documentation
CPR should be withheld when a valid, signed, and dated Do Not Attempt Resuscitation (DNAR) order is present. 1 The documentation must be:
- Portable (wallet card, identification bracelet, or approved paper document) 1
- Clearly written and easily implemented 1
- Approved by the local EMS authority 1
Critical caveat: EMS personnel should not be expected to interpret non-standard advance directives like living wills or durable powers of attorney in the field—these require specific prehospital DNAR protocols. 2
Rescuer Safety
Withhold CPR when attempting resuscitation would place the rescuer at risk of serious injury or mortal peril (e.g., active fire, unstable structure, violent scene). 1
When to START CPR Despite Uncertainty
The American Heart Association guidelines emphasize that without objective signs of irreversible death and in the absence of valid DNAR orders, full resuscitation should be offered. 1 This is because:
- Brain death and irreversible brain damage cannot be reliably assessed at the time of cardiac arrest 1
- The risk of providing CPR to someone not in cardiac arrest is minimal compared to the catastrophic risk of withholding CPR from someone who is 1
- The risk:benefit ratio strongly favors providing CPR for presumed cardiac arrest 1
Special Considerations for Pediatric Traumatic Arrest
In pediatric out-of-hospital traumatic cardiac arrest, withhold resuscitation when:
- Injuries obviously incompatible with life (decapitation, hemicorporectomy) are present 1
- Significant time has elapsed with evidence of dependent lividity, rigor mortis, or decomposition 1
However, initiate standard resuscitation for pediatric arrests from lightning strike or drowning with significant hypothermia, unless the above signs of irreversible death are present. 1
Common Pitfalls to Avoid
- Do not rely on verbal family statements alone without proper DNAR documentation—this requires specific local protocols that authorize honoring verbal requests 3
- Do not use "futility" as sole justification for withholding CPR except when irreversible death signs are present 1
- Do not attempt to assess prognosis or quality of life in the field—these determinations cannot be made reliably during cardiac arrest 1
- Avoid "slow codes" (token resuscitation efforts)—if you start CPR, provide full, high-quality resuscitation 1
When Doubt Exists
If there is any uncertainty about the circumstances, timing, or validity of a DNAR order, initiate full resuscitation and continue until arrival at the appropriate facility. 1 Withholding resuscitation and discontinuing resuscitation are ethically equivalent, so starting CPR while gathering information is the safest approach. 1